MENTAL HEALTH ACT 1983 SECTION 12(2)

APPLICATION FORM FOR APPROVAL/RE-APPROVAL IN WALES

PRIVATE AND CONFIDENTIAL

Betsi Cadwaladr University Local Health Board on behalf of the Welsh Ministers request by a medical practitioner for approval under section 12(2) of the Mental Health Act 1983

Please print and use black ink – all questions must be answered in full

First Names: …………………………………. Surname: ………………………………..
Previous Surname: …………………………. Date of Birth: ……………………………
Designation: .………………………………… Speciality : ..…………………………….
GMC Status and Registration Number: ……………………………………………………
Work Address: ………………………………………………………………………………….
………………………………………………………………………………………………………
Please indicate which phone numbers can be used for the register:
Phone Number (daytime): …………………………………….. YES/NO (Please circle)
Phone Number (out of hours): ……………………………….. YES/NO (Please circle)
Mobile Phone Number: …………………………………………. YES/NO (Please circle)
Email address: ……………………………………………………
The applicant understands that if section 12(2) approval is granted, pursuant to this application, the practitioner’s name, employment address, telephone numbers, designation, speciality and re-approval date will be added to the Register of section 12(2) approved practitioners. The Register is maintained by Betsi Cadwaladr University Health Board in accordance with the Statutory Code of Practice implemented under section 118 of the Mental health Act 1983, and copies will be circulated to the following agencies, Directors of Social Services, LHBs, Mental Health Services, Police Authorities, Police Surgeons and Courts.
I give permission for my details to be held on the confidential electronic database and entered into both the confidential paper and electronic register which will be distributed to relevant agencies.
Signed: ………………………………………. Date……………

Are you seeking approval renewal of approval
Have you ever been refused approval/re-approval by another Local Health Board or Primary Care Trust, if so by which one and why?
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Professional qualifications: ………………………………………………………………
…………………………………………………………………………………………………..
Present Appointment: Locum/Substantive/Retired/Independent/Other: ………….
Date of Appointment: …………………………………………
Speciality: ……………………………………………………….
Employing Authority: ..…………………………………………
Local Health Board: ..………………………………………….
Please give the date and place of the last section 12(2) training course attended:
Date: ……………………………………… Place: ………………………………………….
For GPs – Do you have an up-to-date appraisal record? YES/NO (Please circle)
For Psychiatrists – are you in good standing in CPD/PDP in the RCPsych
Scheme and have an up-to- date appraisal YES/NO (Please circle)
If no to the above, do you have an up to date PDP? YES/NO (Please circle)
If approval has previously been granted by another LHB or PCT, please state:
a) LHB/PCT granting approval: …………………………………………………………..
b) Expiry Date: ………………………………………………….
Please enclose a copy of your approval letter/certificate with this application

PRIVATE AND CONFIDENTIAL

Please confirm which statement relates to you by ticking one of the boxes below:-
·  I do not have to undertake the two supervised mental health act assessments
□
·  The supervisors have forwarded the two completed mental health act assessment forms
Please ensure you have attached the following documents:-
1.  Certificate of attendance at section 12(2) induction/refresher training course
2.  Two references supplied by a section 12(2) doctor
3.  Copy of an up to date curriculum vitae
4.  Any documentation required to meet Criteria A, B or C as appropriate. □
Those employments concerning the care of the elderly, sick or disabled are exempt from the Rehabilitation of Offenders Act 1974 and applicants are therefore not entitled to withhold information about “spent” convictions. Any information given will be treated confidentially and considered only in relation to the application.
Have you ever been convicted of a criminal offence YES/NO (please circle)
If so, please give details: ………………………………………………………………….
I declare the information I have provided is true and accurate
Signature: ……………………………………….. Date: …………………………………..

To be submitted to:

AC and section 12(2) Project Manager/Project Support Manager

Betsi Cadwaladr University Health Board

Betsi Cadwaladr University Technology Park

Rhyd Broughton Lane

Wrexham

LL13 7YP

PRIVATE AND CONFIDENTIAL

DECLARATION FOR MEDICAL STAFF SEEKING APPROVAL UNDER SECTION 12(2) OF THE MENTAL HEALTH ACT 1983

The following information is required in accordance with the Criminal Justice and Court Services Act (Part II) (2000). Please see below for a full explanation.

1.  Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations, which might lead to a conviction, an order binding you over or a caution in the UK or any other county?

Yes/No (please delete as appropriate)

If yes, please provide details of the criminal offence, order binding you over or caution or details of any current proceedings which might lead to a conviction, an order binding you over or a caution, including approximate date, the offence, and the authority and county which dealt with the offence.

……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………

2.  Have you been or are you currently subject to any fitness to practise proceedings by an appropriate licensing or regulatory body in the UK or any other country?

Yes/No (Please delete as appropriate)

If yes, please provide details of the nature of proceedings undertaken, or contemplated including approximate date of proceedings, country where proceedings were undertaken and the name and address of the licensing or regulatory body concerned.

……………………………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………

I hereby declare that the information given here is true.

Signature: ……………………………………………… Date: …………………………….

Full Name: ………………………………………………………………….(Block Capitals)

PRIVATE AND CONFIDENTIAL

Statement of Policy relating to the Criminal Records Bureau (CRB) Code of Practice and Welsh Health Circulars, WHC (2005) 029 ‘Mandatory Criminal Records Bureau (CRB) Checks for All Eligible New NHS Staff’ and WHC (2005) 071 ‘Safer Recruitment – A Guide for NHS Employers

Registration with the General Medical Council imposes on doctors the duty to provide a good standard of medical care for, and behave appropriately, towards patients. NHS Employers also have a duty to ensure that patients receive a good standard of medical care and ensure as far as possible the safety of patients. We therefore need to establish if you have been found guilty of a criminal offence, been bound over or cautioned or are currently the subject of proceedings which might lead to a conviction, an order binding you over or a caution, in the UK or any other country.

Applicants for posts in the NHS are exempt from the Rehabilitation of Offenders Act 1974. The application form includes a declaration for applicants to complete declaring any previous or pending prosecutions or convictions, including those considered “spent” under this Act. Any cautions or bind-overs should also be disclosed.

We also need to establish if you have been the subject of any fitness to practise proceedings in the past, or if any fitness to practice proceedings are being contemplated, by a licensing or regulatory body in the UK or another country and this is also reflected in the declaration.

This information will be treated in confidence and will not debar you from approval unless the panel considers that it renders you unsuitable for approval. In reaching such a decision we will consider the nature of the conviction/action, how long ago it took place and any other factors which may be relevant.

Failure to disclose a criminal offence, having been bound over or cautioned or that you are currently the subject of criminal proceedings undertaken or being undertaken by an appropriate licensing or regulatory body, may disqualify you from approval, or result in withdrawal of approval and referral to the General medical Council for consideration if such a discrepancy came to light.

If you would like to discuss what effect any previous convictions police investigations or fitness to practise proceedings taken or being taken either in the UK or by an overseas licensing or regulatory body might have on your application, you may telephone the AC/S12(2) Project Manager/Project Support Manager at Betsi Cadwaladr Univeristy Health Board on 01978 346522.

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S12v4 15.10.2009